Patient-reported outcome measures in spine surgery: A systematic review

Background

Steadily increasing expenditure in the United States health-care system has led to a shift toward a value-based model that focuses on quality of care and cost-effectiveness. Operations involving the spine rank among some of the most common and expensive procedures performed in operating rooms nationwide. Patient-reported outcomes measures (PROMs) are a useful tool for reporting levels of outcome and analyzing patient recovery but are both under-utilized and nonstandardized in spine surgery.

Methods

We conducted a systematic review of the literature using the PubMed database, focusing on the most commonly utilized PROMs for spine disease as well as spinal deformity. The benefits and drawbacks of these PROMs were then summarized and compared.

Results

Spine-specific PROMs were based on the class of disease. The most frequently utilized PROMs were the Neck Disability Index and the modified Japanese Orthopaedic Association scale; the Oswestry Disability Index and the Roland-Morris Disability Questionnaire; and the Scoliosis Research Society 22-item questionnaire (SRS-22) for cervicothoracic spine disease, lumbar spine disease, and spinal deformity, respectively.

Conclusion

We found limited, though effective, use of PROMs targeting specific classes of disease within spine surgery. Therefore, we advocate for increased use of PROMs in spine surgery, in both the research and clinical settings. PROM usage can help physicians assess subjective outcomes in standard ways that can be compared across patients and institutions, more uniquely tailor treatment to individual patients, and engage patients in their own medical care.

Variability in Acetabular Component Position in Patients Undergoing Direct Anterior Approach Total Hip Arthroplasty Who Have Concomitant Spine Pathology

BACKGROUND

Hip instability following total hip arthroplasty (THA) can be a major cause of revision surgery. Physiological patient position impacts acetabular anteversion and abduction, and influences the functional component positioning. Osteoarthritis of the spine leads to abnormal spinopelvic biomechanics and motion, but there is no consensus on the degree of component variability for THAs performed by anterior approach. Therefore, we sought to present guidelines for changes in acetabular component positioning between supine and standing positions for patients undergoing primary THA by a uniform anterior approach.

METHODS

Perioperative patient radiographs of the pelvis and lumbar spine were collected. Images were used to determine acetabular component positioning and degree of coexisting spinal pathology, categorized as a Lane Grade (LG). Final analysis of variance was performed on a sample size of 643 anterior primary THAs.

RESULTS

From supine to standing position, as the severity of lumbar pathology increased the change in anteversion also increased (LG:0 = -0.11° ± 4.65°, LG:1 = 2.02° ± 4.09°, LG:2-3 = 5.78° ± 5.72°, P < .001). The mean supine anteversion in patients with absent lumbar pathology was 19.72° ± 5.05° and was lower in patients with worsening lumbar pathology (LG:1 = 18.25° ± 4.81°, LG:2-3 = 16.73° ± 5.28°, P < .001).

CONCLUSION

Patients undergoing primary THA by anterior approach with worsening spinal pathology have larger increases in component anteversion when transitioning from supine to standing positions. Consideration should be given to this expected variability when placing the patient's acetabular component.

A Multivariate Analysis to Predict Total Hip Arthroplasty Dislocation With Preoperative Diagnosis, Surgical Approach, Spinal Pathology, Cup Orientation, and Head Size

BACKGROUND

There are several risk factors for dislocation after total hip arthroplasty (THA), but few studies include radiographic assessment of implants, with spine pathology and patient characteristics. This study estimates the rate of dislocation by patient gender, age, race/ethnicity, body mass index, Charlson Comorbidity Index, spine pathology, prior spine fusion, levels affected, radiographic Kellgren-Lawrence score of spine osteoarthritis, THA indication, surgical approach, and femoral head size.

METHODS

Seventy-six primary THA patients between January 2007 and 2020 with a dislocation were matched on age and gender to subjects without a known history of dislocation using a 2:1 allocation. Univariable and multivariable survival models that account for matched strata were used to estimate the rate of dislocation.

RESULTS

Median follow-up of patients at risk for dislocation was 26.48 months (95% confidence interval [CI] 23.75-36.40). On multivariable analysis, patients with an indication other than primary osteoarthritis were 3.69 (95% CI 2.22-6.13, P < .001) times more likely to dislocate than those with osteoarthritis. Patients with a spine pathology were also nominally more likely to dislocate (hazard ratio 1.76, 95% CI 0.97-3.18, P = .06), and patients receiving a posterior surgical approach were 2.74 (95% CI 1.11-6.76, P = .03) times more likely than those receiving a non-posterior approach to dislocate.

CONCLUSION

Patients with THA indication other than primary osteoarthritis and receiving a posterior surgical approach, and to a lesser degree spinal pathology, were identified as affecting the rate of dislocation. After correcting for other variables, femoral head size, cup orientation, and patient factors were not predictive.

LEVEL OF EVIDENCE

Level IV, case-control study.

Canine models of spine disorders

Neck and low back pain are common among the adult human population and impose large social and economic burdens on health care and quality of life. Spine-related disorders are also significant health concerns for canine companions with etiopathogeneses, clinical presentations, and diagnostic and therapeutic options that are very similar to their human counterparts. Historically, induced and spontaneous pathology in laboratory rodents, dogs, sheep, goats, pigs, and nonhuman primates have been used for study of human spine disorders. While each of these can serve as useful preclinical models, they all have inherent limitations. Spontaneously occurring spine disorders in dogs provide highly translatable data that overcome many of the limitations of other models and have the added benefit of contributing to veterinary healthcare as well. For this scoping review, peer-reviewed manuscripts were selected from PubMed and Google Scholar searches using keywords: "intervertebral disc," "intervertebral disc degeneration," "biomarkers," "histopathology," "canine," and "mechanism." Additional keywords such as "injury," "induced model," and "nucleus degeneration" were used to further narrow inclusion. The objectives of this review were to (a) outline similarities in key features of spine disorders between dogs and humans; (b) describe relevant canine models; and (c) highlight the applicability of these models for advancing translational research and clinical application for mechanisms of disease, diagnosis, prognosis, prevention, and treatment, with a focus on intervertebral disc degeneration. Best current evidence suggests that dogs share important anatomical, physiological, histological, and molecular components of spinal disorders in humans, such that induced and spontaneous canine models can be very effective for translational research. Taken together, the peer-reviewed literature supports numerous advantages for use of canine models for study of disorders of the spine when the potential limitations and challenges are addressed.

Contemporary Primary Total Knee Arthroplasty is Durable in Patients Diagnosed With Ankylosing Spondylitis

INTRODUCTION

Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy affecting the axial spine and peripheral joints. Despite innovations in medical management, patients with AS experience two-fold the lifetime risk of total knee arthroplasty (TKA) compared to the general population. Moreover, recent data have indicated a correlation between spinal pathology and outcomes of TKAs.

METHODS

Our institutional total joint registry identified 19 patients (28 knees) with a diagnosis of AS treated with primary TKA from 2000 to 2016. The mean age at TKA was 68 years, and 84% of patients were men. The mean follow-up period was 6 years. Outcomes included implant survivorship, clinical outcomes, and complications.

RESULTS

Survivorship free from any revision was 88% at 10 years. A single patient required revision at 8 years for aseptic loosening. Survivorship free from any reoperation was 77% at 10 years. Reoperations included 2 manipulations under anesthesia and 1 superficial wound irrigation and debridement. Mean Knee Society score improved from 46 preoperatively to 89 postoperatively (P < .0001). The mean arc of motion improved from 108^o preoperatively to 116° postoperatively (P = .01). There were 6 complications that did not require reoperation.

CONCLUSION

Primary TKAs in patients with AS resulted in significant improvement in clinical outcomes with excellent 10-year implant survivorship. Although 2 manipulations under anesthesia were required, the range of motion was restored postoperatively. These data suggest that the contemporary primary TKA can achieve durable and reliable outcomes in patients with axial skeletal disease resulting from AS.

LEVEL OF EVIDENCE

IV.

Stand-to-Sit Kinematics of the Pelvis Is Not Always as Expected: Hip and Spine Pathologies Can Have an Impact

BACKGROUND

Stand-to-sit pelvis kinematics is commonly considered as a rotation around the bicoxofemoral axis. However, abnormal kinematics could occur for patients with musculoskeletal disorders, affecting the hip-spine complex. The aim of this study is to perform a quantitative analysis of the stand-to-sit pelvis kinematics using 3D reconstruction from biplanar x-rays.

METHODS

Thirty volunteers as a control group (C), 30 patients with hip pathology (Hip), and 30 patients with spine pathology (Spine) were evaluated. All subjects underwent standing and sitting full-body biplanar x-rays. Three-dimensional reconstruction was performed in each configuration and then translated such as the middle of the line joining the center of each acetabulum corresponds to the origin. Rigid registration quantified the finite helical axis (FHA) describing the transition between standing and sitting with two specific parameters. The orientation angle (OA) is the signed 3D angle between FHA and bicoxofemoral axis, and the rotation angle (RA) represents the signed angle around FHA.

RESULTS

The mean OA was -1.8° for the C group, 0.3° for Hip group, and -2.4° for Spine group. There was no significant difference in mean OA between groups. However, variability was higher for the Spine group with a standard deviation (SD) of 15.9° compared with 10.8° in the C group and 12.3° in the Hip group. The mean RA in the C group was 18.1° (SD, 9.0°). There was significant difference in RA between the Hip and Spine groups (21.1° [SD, 8.0°] and 16.4° [SD, 10.8°], respectively) (P = .04).

CONCLUSION

Hip and spine pathologies affect stand-to-sit pelvic kinematics.

Early fear memory defects are associated with altered synaptic plasticity and molecular architecture in the TgCRND8 Alzheimer's disease mouse model

Alzheimer's disease (AD) is a complex and slowly progressing dementing disorder that results in neuronal and synaptic loss, deposition in brain of aberrantly folded proteins, and impairment of spatial and episodic memory. Most studies of mouse models of AD have employed analyses of cognitive status and assessment of amyloid burden, gliosis, and molecular pathology during disease progression. Here we sought to understand the behavioral, cellular, ultrastructural, and molecular changes that occur at a pathological stage equivalent to the early stages of human AD. We studied the TgCRND8 mouse, a model of aggressive AD amyloidosis, at an early stage of plaque pathology (3 months of age) in comparison to their wildtype littermates and assessed changes in cognition, neuron and spine structure, and expression of synaptic glutamate receptor proteins. We found that, at this age, TgCRND8 mice display substantial plaque deposition in the neocortex and hippocampus and impairment on cued and contextual memory tasks. Of particular interest, we also observed a significant decrease in the number of neurons in the hippocampus. Furthermore, analysis of CA1 neurons revealed significant changes in apical and basal dendritic spine types, as well as altered expression of GluN1 and GluA2 receptors. This change in molecular architecture within the hippocampus may reflect a rising representation of inherently less stable thin spine populations, which can cause cognitive decline. These changes, taken together with toxic insults from amyloid-β protein, may underlie the observed neuronal loss.